acute coronary syndromes pharmacology

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ACLS Pharmacology

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Objectives

To review and obtain a better understanding of medications used in ACLS– Indications & Actions (When & Why?)– Dosing (How?)– Contraindications & Precautions (Watch

Out!)

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Drug Classifications

Class I: Recommendations– Excellent evidence provides support– Proven in both efficacy and safety

Class II: Recommendations– Level I studies are absent, inconsistent or lack

power– Available evidence is positive but may lack efficacy– No evidence of harm

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Class IIa Vs IIb– Class IIa recommendations have

Higher level of available evidenceBetter critical assessmentsMore consistency in results

– Both are optional and acceptable,– IIa recommendations are probably useful– IIb recommendations are possibly helpful

Less compelling evidence for efficacy

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Class III: Not recommended– Not acceptable or useful and may be

harmful– Evidence is absent or unsatisfactory, or

based on poor studies Indeterminate

– Continuing area of research; no recommendation until further data is available

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Oxygen

Indications (When & Why?)– Any suspected cardiopulmonary emergency– Saturate hemoglobin with oxygen– Reduce anxiety & further damage – Note: Pulse oximetry should be monitored

Universal Algorithm

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Oxygen

Dosing (How?)

Device Flow Rate Oxygen %Nasal Prongs 1 to 6 lpm 24 to 44%

Venturi Mask 4 to 8 lpm 24 to 40%

Partial Rebreather Mask

6 to 10 lpm 35 to 60%

Bag Mask 15 lpm up to 100%

Universal Algorithm

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Oxygen

Precautions (Watch Out!)– Pulse oximetry inaccurate in:

Low cardiac output VasoconstrictionHypothermia

– NEVER rely on pulse oximetry!

Universal Algorithm

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VF / Pulseless VT

Case 3

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VF / Pulseless VT

•Epinephrine 1 mg IV push, repeat every 3 to 5 minutesor

•Vasopressin 40 U IV, single dose, 1 time only

Resume attempts to defibrillate1 x 360 J (or equivalent biphasic) within 30 to 60 seconds

Consider antiarrhythmics:•Amiodarone (llb for persistent or recurrent VF/pulseless VT)•Lidocaine (Indeterminate for persistent or recurrent VF/pulseless VT)•Magnesium (llb if known hypomagnesemic state)•Procainamide (Indeterminate for persistent VF/pulseless VT;

llb for recurrent VF/pulseless VT)

Resume attempts to defibrillate

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Epinephrine

Indications (When & Why?) – Increases:

Heart rateForce of contractionConduction velocity

– Peripheral vasoconstriction– Bronchial dilation

VF / Pulseless VT

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Epinephrine

Dosing (How?)– 1 mg IV push; may repeat every 3 to 5

minutes– May use higher doses (0.2 mg/kg) if lower

dose is not effective– Endotracheal Route

2.0 to 2.5 mg diluted in 10 mL normal saline

VF / Pulseless VT

14

Epinephrine

Dosing (How?)– Alternative regimens for second dose (Class

IIb)Intermediate: 2 to 5 mg IV push, every 3 to 5

minutesEscalating: 1 mg, 3 mg, 5 mg IV push, each

dose 3 minutes apartHigh: 0.1 mg/kg IV push, every 3 to 5 minutes

VF / Pulseless VT

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Epinephrine

Precautions (Watch Out!)– Raising blood pressure and increasing heart

rate may cause myocardial ischemia, angina, and increased myocardial oxygen demand

– Do not mix or give with alkaline solutions– Higher doses have not improved outcome &

may cause myocardial dysfunction

VF / Pulseless VT

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Vasopressin

Indications (When & Why?)– Used to “clamp” down on vessels– Improves perfusion of heart, lungs, and brain– No direct effects on heart

VF / Pulseless VT

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Vasopressin

Dosing (How?)– One time dose of 40 units only– May be substituted for epinephrine– Not repeated at any time– May be given down the endotracheal tube

DO NOT double the doseDilute in 10 mL of NS

VF / Pulseless VT

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Vasopressin

Precautions (Watch Out!)– May result in an initial increase in blood

pressure immediately following return of pulse

– May provoke cardiac ischemia

VF / Pulseless VT

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Amiodarone

Indications (When & Why?)– Powerful antiarrhythmic with substantial

toxicity, especially in the long term – Intravenous and oral behavior are quite

different – Has effects on sodium & potassium

VF / Pulseless VT

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Amiodarone

Dosing (How?)– Should be diluted in 20 to 30 mL of D5W

300 mg bolus after first Epinephrine doseRepeat doses at 150 mg

VF / Pulseless VT

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Amiodarone

Precautions (Watch Out!)– May produce vasodilation & shock– May have negative inotropic effects– Terminal elimination

Half-life lasts up to 40 days

VF / Pulseless VT

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Lidocaine

Indications (When & Why?) – Depresses automaticity– Depresses excitability– Raises ventricular fibrillation threshold– Decreases ventricular irritability

VF / Pulseless VT

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Lidocaine

Dosing (How?)– Initial dose: 1.0 to 1.5 mg/kg IV– For refractory VF may repeat 1.0 to 1.5

mg/kg IV in 3 to 5 minutes; maximum total dose, 3 mg/kg

– A single dose of 1.5 mg/kg IV in cardiac arrest is acceptable

– Endotracheal administration: 2 to 2.5 mg/kg diluted in 10 mL of NS

VF / Pulseless VT

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Lidocaine

Dosing (How?)– Maintenance Infusion

2 to 4 mg/min

1000 mg / 250 mL D5W = 4 mg/mL– 15 mL/hr = 1 mg/min– 30 mL/hr = 2 mg/min– 45 mL/hr = 3 mg/min– 60 mL/hr = 4 mg/min

VF / Pulseless VT

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Lidocaine

Precautions (Watch Out!)– Reduce maintenance dose (not loading

dose) in presence of impaired liver function or left ventricular dysfunction

– Discontinue infusion immediately if signs of toxicity develop

VF / Pulseless VT

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Magnesium Sulfate

Indications (When & Why?)– Cardiac arrest associated with torsades de

pointes or suspected hypomagnesemic state– Refractory VF– VF with history of ETOH abuse– Life-threatening ventricular arrhythmias due

to digitalis toxicity, tricyclic overdose

VF / Pulseless VT

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Magnesium Sulfate

Dosing (How?)– 1 to 2 g (2 to 4 mL of a 50% solution)

diluted in 10 mL of D5W IV push

VF / Pulseless VT

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Magnesium Sulfate

Precautions (Watch Out!)– Occasional fall in blood pressure with rapid

administration– Use with caution if renal failure is present

VF / Pulseless VT

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Procainamide

Indications (When & Why?)– Recurrent VF– Depresses automaticity– Depresses excitability– Raises ventricular fibrillation threshold– Decreases ventricular irritability

VF / Pulseless VT

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Procainamide

Dosing (How?)– 30 mg/min IV infusion – May push at 50 mg/min in cardiac arrest– In refractory VF/VT, 100 mg IV push doses

given every 5 minutes are acceptable– Maximum total dose: 17 mg/kg

VF / Pulseless VT

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Procainamide


1 to 4 mg/min

1000 mg / 250 mL of D5W = 4 mg/mL– 15 mL/hr = 1 mg/min– 30 mL/hr = 2 mg/min– 45 mL/hr = 3 mg/min– 60 mL/hr = 4 mg/min

VF / Pulseless VT

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Procainamide

Precautions (Watch Out!)– If cardiac or renal dysfunction

is present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min

– Remember Endpoints of Administration

VF / Pulseless VT

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PEA

Case 4

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PEA

Atropine 1 mg IV (if PEA rate is slow),repeat every 3 to 5 minutes as needed, to a totaldose of 0.04 mg/kg

• Hypovolemia• Hypoxia• Hydrogen ion—acidosis• Hyper-/hypokalemia• Hypothermia

• Tablets (drug OD, accidents)• Tamponade, cardiac• Tension pneumothorax• Thrombosis, coronary (ACS)• Thrombosis, pulmonary (embolism)

Review for most frequent causes

Epinephrine 1 mg IV push,repeat every 3 to 5 minutes

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Epinephrine




Pulseless Electrical Activity

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Epinephrine






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Epinephrine






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Atropine Sulfate

Indications (When & Why?)– Should only be used for bradycardia

Relative or Absolute

– Used to increase heart rate


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Atropine Sulfate

Dosing (How?)– 1 mg IV push – Repeat every 3 to 5 minutes– May give via ET tube (2 to 2.5 mg) diluted

in 10 mL of NS– Maximum Dose: 0.04 mg/kg


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Atropine Sulfate

Precautions (Watch Out!)– Increases myocardial oxygen demand– May result in unwanted tachycardia or

dysrhythmia


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Asystole

Case 5

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AsystoleTranscutaneous pacing:

If considered, perform immediately

Epinephrine 1 mg IV push,repeat every 3 to 5 minutes

Atropine 1 mg IV,repeat every 3 to 5 minutesup to a total of 0.04 mg/kg

Asystole persistsWithhold or cease resuscitation efforts?

• Consider quality of resuscitation?• Atypical clinical features present?• Support for cease-efforts protocols in place?

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Epinephrine




Asystole: The Silent Heart Algorithm

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Epinephrine






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Epinephrine






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Atropine Sulfate

Indications (When & Why?)– Used to increase heart rate

Questionable absolute bradycardia


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Atropine Sulfate

Dosing (How?)– 1 mg IV push – Repeat every 3 to 5 minutes– May give via ET tube (2 to 2.5 mg) diluted



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Atropine Sulfate

Precautions (Watch Out!)– Increases myocardial oxygen demand


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Other Cardiac Arrest Drugs

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Calcium Chloride

Indications (When & Why?)– Known or suspected hyperkalemia (eg, renal

failure)– Hypocalcemia (blood transfusions)– As an antidote for toxic effects of calcium

channel blocker overdose– Prevent hypotension caused by calcium

channel blockers administration


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Calcium Chloride

Dosing (How?)– IV Slow Push

8 to 16 mg/kg (usually 5 to 10 mL) IV for hyperkalemia and calcium channel blocker overdose

2 to 4 mg/kg (usually 2 mL) IV for prophylactic pretreatment before IV calcium channel blockers


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Calcium Chloride

Precautions (Watch Out!)– Do not use routinely in cardiac arrest– Do not mix with sodium bicarbonate


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Sodium Bicarbonate

Indications (When & Why?)– Class I if known preexisting hyperkalemia– Class IIa if known preexisting bicarbonate-

responsive acidosis– Class IIb if prolonged resuscitation with effective

ventilation; upon return of spontaneous circulation– Class III (not useful or effective) in hypoxic lactic

acidosis or hypercarbic acidosis (eg, cardiac arrest and CPR without intubation)


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Sodium Bicarbonate

Dosing (How?)– 1 mEq/kg IV bolus– Repeat half this dose every 10 minutes

thereafter– If rapidly available, use arterial blood gas

analysis to guide bicarbonate therapy (calculated base deficits or bicarbonate concentration)


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Sodium Bicarbonate

Precautions (Watch Out!)– Adequate ventilation and CPR, not

bicarbonate, are the major "buffer agents" in cardiac arrest

– Not recommended for routine use in cardiac arrest patients


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Acute Coronary Syndromes

Case 6

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Immediate assessment (<10 minutes)• Measure vital signs (automatic/standard BP cuff)• Measure oxygen saturation• Obtain IV access• Obtain 12-lead ECG (physician reviews)• Perform brief, targeted history and physical exam;

focus on eligibility for fibrinolytic therapy• Obtain initial serum cardiac marker levels• Evaluate initial electrolyte and coagulation studies• Request, review portable chest x-ray (<30 minutes)

Chest painsuggestive of ischemia

Immediate general treatment• Oxygen at 4 L/min• Aspirin 160 to 325 mg• Nitroglycerin SL or spray• Morphine IV (if pain not relieved with

nitroglycerin)

Memory aid: “MONA” greetsall patients (Morphine, Oxygen, Nitroglycerin, Aspirin)

EMS personnel canperform immediateassessment and treat-ment (“MONA”),including initial 12-lead

ECG and review forfibrinolytic therapyindications andcontraindications.

Assess initial 12-lead ECG

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Aspirin

Indications (When & Why?)– Administer to all patients with ACS,

particularly reperfusion candidatesGive as soon as possible

– Blocks formation of thromboxane A2, which causes platelets to aggregate


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Aspirin

Dosing (How?)– 160 to 325 mg tablets

Preferably chewedMay use suppository

– Higher doses may be harmful


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Aspirin

Precautions (Watch Out!)– Relatively contraindicated in patients with

active ulcer disease or asthma


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Nitroglycerine

Indications (When & Why?)– Chest pain of suspected cardiac origin– Unstable angina– Complications of AMI, including congestive

heart failure, left ventricular failure– Hypertensive crisis or urgency with chest

pain


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Nitroglycerin

Indications (When & Why?)– Decreases pain of ischemia– Increases venous dilation– Decreases venous blood return to heart – Decreases preload and cardiac

oxygen consumption– Dilates coronary arteries– Increases cardiac collateral flow


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Nitroglycerine

Dosing (How?)– Sublingual Route

0.3 to 0.4 mg; repeat every 5 minutes– Aerosol Spray

Spray for 0.5 to 1.0 second at 5 minute intervals– IV Infusion

Infuse at 10 to 20 µg/minRoute of choice for emergenciesTitrate to effect


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Nitroglycerine

Precautions (Watch Out!)– Use extreme caution if systolic BP <90 mm Hg– Use extreme caution in RV infarction

– Suspect RV infarction with inferior ST changes

– Limit BP drop to 10% if patient is normotensive– Limit BP drop to 30% if patient is hypertensive– Watch for headache, drop in BP, syncope,

tachycardia– Tell patient to sit or lie down during administration


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Morphine Sulfate

Indications (When & Why?)– Chest pain and anxiety associated with AMI

or cardiac ischemia– Acute cardiogenic pulmonary edema (if

blood pressure is adequate)


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Morphine Sulfate

Indications (When & Why?)– To reduce pain of ischemia– To reduce anxiety– To reduce extension of ischemia by reducing

oxygen demands


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Morphine Sulfate

Dosing (How?)– 1 to 3 mg IV (over 1 to 5 minutes) every 5 to

10 minutes as needed


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Morphine Sulfate

Precautions (Watch Out!)– Administer slowly and titrate to effect– May compromise respiration; therefore use

with caution in acute pulmonary edema– Causes hypotension in volume-depleted

patients


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• ST elevation or new or presumably new LBBB:

strongly suspicious for injury

• ST-elevation AMI

• ST depression or dynamicT-wave inversion:

strongly suspicious for ischemia

• High-risk unstable angina/non–ST-elevation AMI

• Nondiagnostic ECG:absence of changes in ST segment or T waves

• Intermediate/low-riskunstable angina

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ST Elevation

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Recognition of AMI

Know what to look for—– ST elevation >1 mm– 3 contiguous leads

Know where to look– Refer to 2000 ECC

HandbookPR baseline

ST-segment deviation= 4.5 mm

J point plus0.04 second

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ST Elevation

Baseline

Ischemia—tall or inverted T wave (infarct),ST segment may be depressed (angina)

Injury—elevated ST segment, T wave may invert

Infarction (Acute)—abnormal Q wave,ST segment may be elevated and T wavemay be inverted

Infarction (Age Unknown)—abnormal Q wave,ST segment and T wave returned to normal

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Beta Blockers

Indications (When & Why?)– To reduce myocardial ischemia and damage

in AMI patients with elevated heart rates, blood pressure, or both

– Blocks catecholamines from binding to ß-adrenergic receptors

– Reduces HR, BP, myocardial contractility – Decreases AV nodal conduction – Decreases incidence of primary VF


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Beta Blockers

Dosing (How?)– Esmolol

0.5 mg/kg over 1 minute, followed by continuous infusion at 0.05 mg/kg/min

Titrate to effect, Esmolol has a short half-life (<10 minutes)

– Labetalol 10 mg labetalol IV push over 1 to 2 minutes May repeat or double labetalol every 10 minutes to a

maximum dose of 150 mg, or give initial dose as a bolus, then start labetalol infusion 2 to 8 µg/min


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Beta Blockers

Dosing (How?)– Metoprolol

5 mg slow IV at 5-minute intervals to a total of 15 mg

– Atenolol 5 mg slow IV (over 5 minutes) Wait 10 minutes, then give second dose of 5 mg slow IV

(over 5 minutes)

– Propranolol 1 to 3 mg slow IV. Do not exceed 1 mg/min Repeat after 2 minutes if necessary


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Beta Blockers

Precautions (Watch Out!)– Concurrent IV administration with IV calcium

channel blocking agents like verapamil or diltiazem can cause severe hypotension

– Avoid in bronchospastic diseases, cardiac failure, or severe abnormalities in cardiac conduction

– Monitor cardiac and pulmonary status during administration

– May cause myocardial depression


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Heparin

Indications (When & Why?)– For use in ACS patients with Non Q wave MI

or unstable angina– Inhibits thrombin generation by factor Xa

inhibition and also inhibit thrombin indirectly by formation of a complex with antithrombin III


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Heparin

Dosing (How?)– Initial bolus 60 IU/kg

Maximum bolus: 4000 IU

– Continue at 12 IU/kg/hr (maximum 1000 IU/hr for patients < 70 kg), round to the nearest 50 IU


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Heparin

Dosing (How?)– Adjust to maintain activated partial thromboplastin

time (aPTT) 1.5 to 2.0 times the control values for 48 hours or angiography

– Target range for aPTT after first 24 hours is between 50 & 70 seconds (may vary with laboratory)

– Check aPTT at 6, 12, 18, and 24 hours– Follow Institutional Heparin Protocol


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Heparin

Precautions (Watch Out!)– Same contraindications as for fibrinolytic

therapy: active bleeding; recent intracranial, intraspinal or eye surgery; severe hypertension; bleeding disorders; gastroinintestinal bleeding

– DO NOT use if platelet count is below 100 000


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Glycoprotein IIb/IIIa Inhibitors

Indications (When & Why?)– Inhibit the integrin glycoprotein IIb/IIIa

receptor in the membrane of platelets, inhibiting platelet aggregation

– Indicated for Acute Coronary Syndromes without ST segment elevation


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Indications (When & Why?)– Abciximab (ReoPro)

Non Q wave MI or unstable angina with planned PCI within 24 hours

Must use with heparin– Binds irreversibly with platelets– Platelet function recovery requires 48 hours


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Indications (When & Why?)– Eptifibitide (Integrilin)

Non Q wave MI, unstable angina managed medically, and unstable angina / Non Q wave MI patients undergoing PCI

Platelet function recovers within 4 to 8 hours after discontinuation


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Indications (When & Why?)– Tirofiban (Aggrastat)

Non Q wave MI, unstable angina managed medically, and unstable angina / Non Q wave MI patients undergoing PCI

Platelet function recovers within 4 to 8 hours after discontinuation


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Dosing (How?)– NOTE: Check package insert for current

indications, doses, and duration of therapy.

Optimal duration of therapy has NOT been established.


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Dosing (How?)– Abciximab (ReoPro)

ACS with planned PCI within 24 hours– 0.25 mg/kg bolus (10 to 60 minutes before

procedure), then 0.125 mcg/kg/min infusionPCI only

– 0.25 mg/kg bolus– Then 10 mcg/min infusion


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Dosing (How?)– Eptifibitide (Integrilin)

Acute Coronary Syndromes– 180 mcg/kg IV bolus, then 2 mcg/kg/min

infusionPCI

– 135 mcg/kg IV bolus, then begin 0.5 mcg/kg/min infusion, then repeat bolus in 10 minutes


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Dosing (How?)– Tirofiban (Aggrastat)

Acute Coronary Syndromes or PCI– 0.4 mcg/kg/min infusion IV for 30 minutes– Then 0.1 mcg/kg/min infusion


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Precautions (Watch Out!)– Active internal bleeding or bleeding disorder

within 30 days– History of intracranial hemorrhage or other

bleeding– Surgical procedure or trauma within 1 month– Platelet count > 150 000/mm3


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PTCA

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Fibrinolytics

Indications (When & Why?) – For AMI in adults

ST elevation or new or presumably new LBBB; strongly suspicious for injury

Time of onset of symptoms < 12 hours


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Fibrinolytics

Indications (When & Why?) – For Acute Ischemic Stroke

Sudden onset of focal neurologic deficits or alterations in consciousness

Absence of subarachnoid or intracerebral hemorrhage

Alteplase can be started in less than 3 hours of symptom onset


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Fibrinolytics

Dosing (How?)– For fibrinolytic use, all patients should have

2 peripheral IV lines1 line exclusively for fibrinolytic administration


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Fibrinolytics Dosing for AMI Patients (How?)

– Alteplase, recombinant (tPA) Accelerated Infusion

– 15 mg IV bolus– Then 0.75 mg/kg over the next 30 minutes

Not to exceed 50 mg– Then 0.5 mg/kg over the next 60 minutes

Not to exceed 35 mg 3 hour Infusion

– Give 60 mg in the first hour (initial 6 to 10 mg is given as a bolus)

– Then 20 mg/hour for 2 additional hours


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Fibrinolytics Dosing for AMI Patients (How?)

– Anistreplase (APSAC) Reconstitute 30 units in 50 mL of sterile water 30 units IV over 2 to 5 minutes

– Reteplase, recombinant Give first 10 unit IV bolus over 2 minutes 30 minutes later give second 10 unit IV bolus over 2

minutes– Streptokinase

1.5 million IU in a 1 hour infusion– Tenecteplase (TNKase)

Bolus 30 to 50 mg


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Fibrinolytics

Adjunctive Therapy for AMI Patients (How?)– 160 to 325 mg aspirin chewed as soon as

possible– Begin heparin immediately and continue for

48 hours if alteplase or Retavase is used


98

Fibrinolytics

Dosing for Acute Ischemic Stroke (How?)– Alteplase, recombinant (tPA)

Give 0.9 mg/kg (maximum 90 mg) infused over 60 minutes

– Give 10% of total dose as an initial IV bolus over 1 minute

– Give the remaining 90% over the next 60 minutes

– Alteplase is the only agent approved for use in Ischemic Stroke patients


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Fibrinolytics

Precautions (Watch Out!)– Specific Exclusion Criteria

Active internal bleeding (except mensus) within 21 days

History of CVA, intracranial, or intraspinal within 3 months

Major trauma or serious injury within 14 daysAortic dissectionSevere uncontrolled hypertension


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Fibrinolytics

Precautions (Watch Out!)– Specific Exclusion Criteria

Known bleeding disordersProlonged CPR with evidence of thoracic traumaLumbar puncture within 7 daysRecent arterial puncture at noncompressible siteDuring the first 24 hours of fibrinolytic therapy for

ischemic stroke, do not give aspirin or heparin


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ACE Inhibitors

Indications (When & Why?)– Reduce mortality & improve LV dysfunction

in post AMI patients– Help prevent adverse LV remodeling, delay

progression of heart failure, and decrease sudden death & recurrent MI


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ACE Inhibitors

Indications (When & Why?)– Suspected MI & ST elevation in 2 or more

anterior leads– Hypertension– Clinical signs of AMI with LV dysfunction– LV ejection fraction <40%


103

ACE Inhibitors

Indications (When & Why?)– Generally not started in the ED but within

first 24 hours after:Fibrinolytic therapy has been completedBlood pressure has stabilized


104

ACE Inhibitors

Dosing (How?)– Should start with low-dose oral

administration (with possible IV doses for some preparations) and increase steadily to achieve a full dose within 24 to 48 hours


105

ACE Inhibitors

Dosing (How?)– Enalapril

2.5 mg PO titrated to 20 mg BIDIV dosing of 1.25 mg IV over 5 minutes, then

1.25 to 5 mg IV every six hours

– CaptoprilStart with 6.25 mg POAdvance to 25 mg TID, then to 50 mg TID as

tolerated


106

ACE Inhibitors

Dosing (How?)– Lisinopril (AMI dose)

5 mg within 24 hours onset of symptoms10 mg after 24 hours, then 10 mg after 48 hours,

then 10 mg PO daily for six weeks

– RamiprilStart with single dose of 2.5 mg POTitrate to 5 mg PO BID as tolerated


107

ACE Inhibitors

Precautions (Watch Out!)– Contraindicated in pregnancy– Contraindicated in angioedema– Reduce dose in renal failure– Avoid hypotension, especially following initial

dose & in relative volume depletion


108

Bradycardias

Case 7

109

BradycardiaBradycardia

•Slow (absolute bradycardia = rate <60 bpm)or

•Relatively slow (rate less than expected relative to underlying condition or cause)

• Assess ABCs• Secure airway noninvasively• Ensure monitor/defibrillator is available

Primary ABCD Survey

Secondary ABCD Survey• Assess secondary ABCs (invasive airway management

needed?)• Oxygen–IV access–monitor–fluids• Vital signs, pulse oximeter, monitor BP• Obtain and review 12-lead ECG• Obtain and review portable chest x-ray• Problem-focused history• Problem-focused physical examination• Consider causes (differential diagnoses)

110

Bradycardia

Intervention sequence• Atropine 0.5 to 1.0 mg• Transcutaneous pacing if available• Dopamine 5 to 20 µg/kg per minute• Epinephrine 2 to 10 µg/min• Isoproterenol 2 to 10 µg/min

Serious signs or symptoms?Due to bradycardia?

Type II second-degree AV blockor

Third-degree AV block?

Observe • Prepare for transvenous pacer• If symptoms develop, use

transcutaneous pacemaker until transvenous pacer placed

No Yes

YesNo

111

Atropine Sulfate

Indications (When & Why?)– First drug for symptomatic bradycardia

Increases heart rate by blocking the parasympathetic nervous system

Bradycardias

112

Atropine Sulfate

Dosing (How?)– 0.5 to 1.0 mg IV every 3 to 5 minutes as

needed– May give via ET tube (2 to 2.5 mg) diluted


Bradycardias

113

Atropine Sulfate

Precautions (Watch Out!)– Use with caution in presence of myocardial

ischemia and hypoxia– Increases myocardial oxygen demand– Seldom effective for:

Infranodal (type II) AV block Third-degree block (Class IIb)

Bradycardias

114

Dopamine

Indications (When & Why?)– Second drug for symptomatic bradycardia

(after atropine)– Use for hypotension (systolic BP 70 to 100

mm Hg) with S/S of shock

Bradycardias

115

Dopamine

Dosing (How?)– IV Infusions (Titrate to Effect)

– 400 mg / 250 mL of D5W = 1600 mcg/mL– 800 mg/ 250 mL of D5W = 3200 mcg/mL

Bradycardias

116

Dopamine


Low Dose “Renal Dose"– 1 to 5 µg/kg per minute

Moderate Dose “Cardiac Dose"– 5 to 10 µg/kg per minute

High Dose “Vasopressor Dose"– 10 to 20 µg/kg per minute

Bradycardias

117

Dopamine

Precautions (Watch Out!)– May use in patients with hypovolemia but only after

volume replacement– May cause tachyarrhythmias, excessive

vasoconstriction– DO NOT mix with sodium bicarbonate

Bradycardias

118

Epinephrine

Indications (When & Why?) – Symptomatic bradycardia: After atropine,

dopamine, and transcutaneous pacing (Class IIb)

Bradycardias

119

Epinephrine

Dosing (How?)– Profound Bradycardia

2 to 10 µg/min infusion (add 1 mg of 1:1000 to 500 mL normal saline; infuse at 1 to 5 mL/min)

Bradycardias

120

Epinephrine



– Do not mix or give with alkaline solutions

Bradycardias

121

Isoproterenol

Indications (When & Why?)– Temporary control of bradycardia in heart

transplant patients– Class IIb at low doses for symptomatic

bradycardia– Heart Transplant Patients!

Bradycardias

122

Isoproterenol

Dosing (How?)– Infuse at 2 to 10 µg/min– Titrate to adequate heart rate

Bradycardias

123

Isoproterenol

Precautions (Watch Out!)– Increases myocardial oxygen requirements,

which may increase myocardial ischemia– DO NOT administer with poison/drug-

induced shockException: Beta Blocker Poisoning

Bradycardias

124

Stable Tachycardias

Case 9

125

Diltiazem

Indications (When & Why?)– To control ventricular rate in atrial fibrillation

and atrial flutter– Use after adenosine to treat refractory PSVT

in patients with narrow QRS complex and adequate blood pressure

– As an alternative, use verapamil

Stable Tachycardias

126

Diltiazem

Dosing (How?)– Acute Rate Control

15 to 20 mg (0.25 mg/kg) IV over 2 minutesMay repeat in 15 minutes at 20 to 25 mg (0.35

mg/kg) over 2 minutes

– Maintenance Infusion5 to 15 mg/hour, titrated to heart rate

Stable Tachycardias

127

Diltiazem

Precautions (Watch Out!)– Do not use calcium channel blockers for

tachycardias of uncertain origin– Avoid calcium channel blockers in patients with

Wolff-Parkinson-White syndrome, in patients with sick sinus syndrome, or in patients with AV block without a pacemaker

– Expect blood pressure drop resulting from peripheral vasodilation

– Concurrent IV administration with IV ß-blockers can cause severe hypotension

Stable Tachycardias

128

Verapamil

Indications (When & Why?)– Used as an alternative to diltiazem for

ventricular rate control in atrial fibrillation and atrial flutter

– Drug of second choice (after adenosine) to terminate PSVT with narrow QRS complex and adequate blood pressure

Stable Tachycardias

129

Verapamil

Dosing (How?)– 2.5 to 5.0 mg IV bolus over 1to 2 minutes– Second dose: 5 to 10 mg, if needed, in 15 to

30 minutes. Maximum dose: 30 mg– Older patients: Administer over 3 minutes

Stable Tachycardias

130

Verapamil

Precautions (Watch Out!)– Do not use calcium channel blockers for

wide-QRS tachycardias of uncertain origin– Avoid calcium channel blockers in patients

with Wolff-Parkinson-White syndrome and atrial fibrillation, sick sinus syndrome, or second- or third-degree AV block without pacemaker

Stable Tachycardias

131

Verapamil

Precautions (Watch Out!)– Expect blood pressure drop caused by

peripheral vasodilation– IV calcium can restore blood pressure, and

some experts recommend prophylactic calcium before giving calcium channel blockers

– Concurrent IV administration with IV ß-blockers may produce severe hypotension

Stable Tachycardias

132

Adenosine

Indications (When & Why?)– First drug for narrow-complex PSVT– May be used diagnostically (after lidocaine)

in wide-complex tachycardias of uncertain type

Stable Tachycardias

133

Adenosine

Dose (How?)– IV Rapid Push– Initial bolus of 6 mg given rapidly over 1 to 3

seconds followed by normal saline bolus of 20 mL; then elevate the extremity

– Repeat dose of 12 mg in 1 to 2 minutes if needed

– A third dose of 12 mg may be given in 1 to 2 minutes if needed

Stable Tachycardias

134

Adenosine

Precautions (Watch Out!)– Transient side effects include:

Facial FlushingChest painBrief periods of asystole or bradycardia

– Less effective in patients taking theophyllines

Stable Tachycardias

135

Beta Blockers

Indications (When & Why?)– To convert to normal sinus rhythm or to slow

ventricular response (or both) in supraventricular tachyarrhythmias (PSVT, atrial fibrillation, or atrial flutter)

– ß-Blockers are second-line agents after adenosine, diltiazem, or digoxin

Stable Tachycardias

136

Beta Blockers

Dosing (How?)– Esmolol

0.5 mg/kg over 1 minute, followed by continuous infusion at 0.05 mg/kg/min

Titrate to effect, Esmolol has a short half-life (<10 minutes)

– Labetalol 10 mg labetalol IV push over 1 to 2 minutes May repeat or double labetalol every 10 minutes to a

maximum dose of 150 mg, or give initial dose as a bolus, then start labetalol infusion 2 to 8 µg/min

Stable Tachycardias

137

Beta Blockers

Dosing (How?)– Metoprolol

5 mg slow IV at 5-minute intervals to a total of 15 mg

– Atenolol 5 mg slow IV (over 5 minutes) Wait 10 minutes, then give second dose of 5 mg slow IV

(over 5 minutes)

– Propranolol 1 to 3 mg slow IV. Do not exceed 1 mg/min Repeat after 2 minutes if necessary

Stable Tachycardias

138

Beta Blockers

Precautions (Watch Out!)– Concurrent IV administration with IV calcium

channel blocking agents like verapamil or diltiazem can cause severe hypotension

– Avoid in bronchospastic diseases, cardiac failure, or severe abnormalities in cardiac conduction

– Monitor cardiac and pulmonary status during administration

– May cause myocardial depression

Stable Tachycardias

139

Digoxin

Indications (When & Why?)– To slow ventricular response in atrial

fibrillation or atrial flutter– Third-line choice for PSVT

Stable Tachycardias

140

Digoxin

Dosing (How?)– IV Infusion

Loading doses of 10 to 15 µg/kg provide therapeutic effect with minimum risk of toxic effects

Maintenance dose is affected by body size and renal function

Stable Tachycardias

141

Digoxin

Precautions (Watch Out!)– Toxic effects are common and are frequently

associated with serious arrhythmias– Avoid electrical cardioversion unless

condition is life threateningUse lower current settings (10 to 20 Joules)

Stable Tachycardias

142

Amiodarone

Indications (When & Why?)– Powerful antiarrhythmic with substantial

toxicity, especially in the long term – Intravenous and oral behavior are quite

different

Stable Tachycardias

143

Amiodarone

Dosing (How?)– Stable Wide-Complex Tachycardias

Rapid Infusion– 150 mg IV over 10 minutes (15 mg/min)– May repeat

Slow Infusion– 360 mg IV over 6 hours (1 mg/min)

Stable Tachycardias

144

Amiodarone


540 mg IV over 18 hours (0.5 mg/min)

Stable Tachycardias

145

Amiodarone

Precautions (Watch Out!)– May produce vasodilation & shock– May have negative inotropic effects– May prolong QT Interval

DO NOT administer with other drugs that may prolong QT Interval (Procainamide)

– Terminal eliminationHalf-life lasts up to 40 days

Stable Tachycardias

146

Amiodarone

Precautions (Watch Out!)– Contraindicated in:

Second or third degree A-V blockSevere bradycardiaPregnancyCHFHypokalaemiaLiver dysfunction

Stable Tachycardias

147

Lidocaine

Indications (When & Why?) – Depresses automaticity– Depresses excitability– Raises ventricular fibrillation threshold– Decreases ventricular irritability

Stable Tachycardias

148

Lidocaine

Dosing (How?)– For stable VT, wide-complex tachycardia of

uncertain type, significant ectopy, use as follows:

1.0 to 1.5 mg/kg IV pushRepeat 0.5 to 0.75 mg/kg every 5 to 10 minutes;

maximum total dose, 3 mg/kg

Stable Tachycardias

149

Lidocaine


2 to 4 mg/min

Stable Tachycardias

150

Lidocaine

Precautions (Watch Out!)– Reduce maintenance dose (not loading

dose) in presence of impaired liver function or left ventricular dysfunction

– Discontinue infusion immediately if signs of toxicity develop

Stable Tachycardias

151

Magnesium Sulfate

Indications (When & Why?)– Torsades de pointes with a pulse– Wide-complex tachycardia with history of

ETOH abuse– Life-threatening ventricular arrhythmias due

to digitalis toxicity, tricyclic overdose

Stable Tachycardias

152

Magnesium Sulfate

Dosing (How?)– Loading dose of 1 to 2 grams mixed in 50 to

100 mL of D5W IV push over 5 to 60 minutes

Stable Tachycardias

153

Magnesium Sulfate


1 to 4 g/hour IV (titrate dose to control the torsades)

Stable Tachycardias

154

Magnesium Sulfate

Precautions (Watch Out!)– Occasional fall in blood pressure with rapid

administration– Use with caution if renal failure is present

Stable Tachycardias

155

Procainamide

Indications (When & Why?)– Depresses automaticity– Depresses excitability– Raises ventricular fibrillation threshold– Decreases ventricular irritability– Atrial fibrillation with rapid rate in Wolff-

Parkinson-White syndrome

Stable Tachycardias

156

Procainamide

Dosing (How?)– Perfusing Arrhythmia

20 mg/min IV infusion until:– Hypotension develops– Arrhythmia is suppressed– QRS widens by >50%– Maximum dose of 17 mg/kg is reached

In refractory VF/VT, 100 mg IV push doses given every 5 minutes are acceptable

Stable Tachycardias

157

Procainamide


1 to 4 mg/min

Stable Tachycardias

158

Procainamide

Precautions (Watch Out!)– If cardiac or renal dysfunction

is present, reduce maximum total dose to 12 mg/kg and maintenance infusion to 1 to 2 mg/min

– Remember Endpoints of Administration

Stable Tachycardias

159

Acute Ischemic Stroke

Case 10

160


Immediate assessment: <10 minutes from arrival• Assess ABCs, vital signs• Provide oxygen by nasal cannula• Obtain IV access; obtain blood samples (CBC,

electolytes, coagulation studies)• Check blood sugar; treat if indicated• Obtain 12-lead ECG, check for arrhythmias• Perform general neurological screening assessment• Alert Stroke Team: neurologist, radiologist,

CT technician

Immediate neurological assessment: <25 minutes from arrival• Review patient history• Establish onset (<3 hours required for fibrinolytics)• Perform physical examination• Perform neurological examination:

Determine level of consciousness (Glasgow Coma Scale) Determine level of stroke severity (NIH Stroke Scale or

Hunt and Hess Scale)• Order urgent noncontrast CT scan

(door-to–CT scan performed: goal <25 minutes from arrival)• Read CT scan (door-to–CT read: goal <45 minutes from arrival)• Perform lateral cervical spine x-ray (if patient comatose/history

of trauma)

EMS assessments and actions

Immediate assessments performed by EMSpersonnel include• Cincinnati Prehospital Stroke Scale

(includes difficulty speaking, arm weakness, facial droop)

• Los Angeles Prehospital Stroke Screen• Alert hospital to possible stroke patient• Rapid transport to hospital

Suspected Stroke

DetectionDispatchDeliveryDoor

161

Nitroprusside

Indications (When & Why?)– Hypertensive crisis


162

Nitroprusside

Dosing (How?)– Begin at 0.1 mcg/kg/min and titrate upward

every 3 to 5 minutes to desired effectUp to 0.5 mcg/kg/min

– Action occurs within 1 to 2 minutes


163

Nitroprusside

Dosing Precautions (How?)– Use with an infusion pump; use

hemodynamic monitoring for optimal safety– Cover drug reservoir with opaque material


164

Nitroprusside

Precautions (Watch Out!)– Light-sensitive; therefore, wrap drug

reservoir in aluminum foil– May cause hypotension and CO2 retention– May exacerbate intrapulmonary shunting– Other side effects include headaches,

nausea, vomiting, and abdominal cramps


165

Drugs used in Overdoses

166

Calcium Chloride

Indications (When & Why?)– As an antidote for toxic effects of calcium

channel blocker overdose

Drugs Used in Overdoses

167

Calcium Chloride

Dosing (How?)– 8 to 16 mg/kg (usually 5 to 10 mL) IV for

hyperkalemia and calcium channel blocker overdose


168

Calcium Chloride

Precautions (Watch Out!)– Do not use routinely in cardiac arrest– Do not mix with sodium bicarbonate


169

Flumazenil

Indications (When & Why?)– Reduce respiratory depression and sedative

effects from pure benzodiazepine overdose


170

Flumazenil

Dosing (How?)– First Dose

0.2 mg IV over 15 seconds– Second Dose

0.3 mg IV over 30 seconds– Third Dose

0.4 mg IV over 30 seconds– Maximum Dose

3 mg


171

Flumazenil

Precautions (Watch Out!)– Effects may not outlast effects of

benzodiazepines– Monitor for recurrent respiratory depression– DO NOT use in suspected tricyclic overdose– DO NOT use in seizure-prone patients– DO NOT use if unknown type overdose or

mixed drug overdose with drugs known to cause seizures


172

Naloxone Hydrochloride

Indications (When & Why?)– Respiratory and neurologic depression due

to opiate intoxication unresponsive to oxygen and hyperventilation


173


Dosing (How?)– 0.4 to 2 mg IVP every 2 minutes– Use higher doses for complete narcotic

reversal– Can administer up to 10 mg in a short time

(10 minutes)


174


Precautions (Watch Out!)– May cause opiate withdrawal– Effects may not outlast effects of narcotics– Monitor for recurrent respiratory depression


175

Review of Infusions

176

Dobutamine

Indications (When & Why?)– Consider for pump problems (congestive

heart failure, pulmonary congestion) with systolic blood pressure of 70 to 100 mm Hg and no signs of shock

– Increases Inotropy

Review of Infusions

177

Dobutamine

Dosing (How?)– Usual infusion rate is 2 to 20 µg/kg per

minute– Titrate so heart rate does not increase by

more than 10% of baseline– Hemodynamic monitoring is recommended

for optimal use

Review of Infusions

178

Dobutamine

Precautions (Watch Out!)– Avoid when systolic blood pressure <100

mm Hg with signs of shock– May cause tachyarrhythmias, fluctuations in

blood pressure, headache, and nausea– DO NOT mix with sodium bicarbonate

Review of Infusions

179

Dopamine

Indications (When & Why?)– Second drug for symptomatic bradycardia

(after atropine)– Use for hypotension (systolic BP 70 to 100

mm Hg) with S/S of shock

Review of Infusions

180

Dopamine


Low Dose “Renal Dose"– 1 to 5 µg/kg per minute

Moderate Dose “Cardiac Dose"– 5 to 10 µg/kg per minute

High Dose “Vasopressor Dose"– 10 to 20 µg/kg per minute

Review of Infusions

181

Dopamine

Precautions (Watch Out!)– May use in patients with hypovolemia but only after

volume replacement– May cause tachyarrhythmias, excessive

vasoconstriction– DO NOT mix with sodium bicarbonate

Review of Infusions

182

Epinephrine

Indications (When & Why?) – Symptomatic bradycardia: After atropine,

dopamine, and transcutaneous pacing (Class IIb)

Review of Infusions

183

Epinephrine

Dosing (How?)– Profound Bradycardia

2 to 10 µg/min infusion (add 1 mg of 1:1000 to 500 mL normal saline; infuse at 1 to 5 mL/min)

Review of Infusions

184

Epinephrine





Review of Infusions

185

Norepinephrine

Indications (When & Why?)– For severe cardiogenic shock and

hemodynamic significant hypotension (systolic blood pressure < 70 mm/Hg) with low total peripheral resistance

– This is an agent of last resort for management of ischemic heart disease and shock

Review of Infusions

186

Norepinephrine

Dosing (How?)– 0.5 to 1 mcg/min titrated to improve blood

pressure (up to 30 mcg/min)– DO NOT administer is same IV line as

alkaline infusions– Poison/drug-induced hypotension may

higher doses to achieve adequate perfusion

Review of Infusions

187

Norepinephrine

Precautions (Watch Out!)– Increases myocardial oxygen requirements– May induce arrhythmias– Extravasation causes tissue necrosis

Review of Infusions

188

Calculating mg/min

dose X gtt factor

Solution Concentration

2 mg X 60 gtt/mL

4 mg

Using a 60 gtt set: 30 gtt/min = 30 cc/hr

= 30 gtts/min

= gtts/min

189

Calculating mcg/kg/min

dose X kg X gtt factor

solution concentration

5 mcg/min X 75 kg X 60 gtt/mL

1600 mcg/cc

Using a 60 gtt set: 18.75 cc/hr = 18.75 gtts/min

= 18.75 cc/hr

= cc/hr

190

Furosemide

Indications (When & Why?)– For adjuvant therapy of acute pulmonary

edema in patients with systolic blood pressure >90 to 100 mm Hg (without S/S of shock)

– Hypertensive emergencies– Increased intracranial pressure

191

Furosemide

Dosing (How?)– 20 to 40 mg slow IVP– If patient is taking at home, double their daily

dose

192

Furosemide

Precautions (Watch Out!)– Dehydration, hypovolemia, hypotension,

hypokalemia, or other electrolyte imbalance may occur

193

Questions?

Jeremy [email protected]

194

Summary

To obtain a full understanding of ACLS pharmacology requires constant review of:– Indications & Actions (When & Why?)– Dosing (How?)– Contraindications & Precautions (Watch

Out!)

195

Thank You!

acute coronary syndromes pharmacology

Education

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mgmin vf pulseless vt

heart vf pulseless vt

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refractory vf